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What is hypospadias?

Congenital defect in which the urethral opening is not at the end of the penis but is located on the lower or underside of shaft. It is freq. associated with congenital chordee, a fibrous band of tissue that causes ventral curvature of the penis.

What are S/S of hypospadias?

1. Opening of the urethra at a location other than the tip of the penis
2. Downward curve of the penis (chordee)
3. Hooded appearance of the penis because only the top half of the penis is covered by foreskin
4. Abnormal spraying during urination

To enable child (as he grows older) to have a normal
1. sexual relationship
2. be able to urinate standing up.
3. normal appearance

What is the treatment of hypospadias?

Surgical correction.

When is surgery done for hypospadias?

Bone before the age of toilet training, between 6-15 months of age (b/c child will have difficulty with toliet training b/c urine is not eliminated through tip of penis) ALSO.. do procedure before child develops castration and body image anxiety.

Should circumcision be performed on a pt. with hypospadias?

No. b/c the foreskin may be used in surgical reconstruction of the defect.

Post-op priorities for hypospadias?

1. Penis may have a urethral stent or catheter in place (to maintain patency of the urethral opening while the meatus is healing) & be wrapped in a pressure dressing.
2. Encourage fluids to maintain adequate urine output & maintain patency of stent.
3. Monitor urine for I/O & for cloudiness or foul odor.
4. Call physician if no urine output occurs for 1 hr, b/c there could be kinks in the urinary diversion or stent or obstruction by sediment.
5. Restraints may be needed to prevent accidental removal of stent.

What med therapy for hyospadias is reccomended?

Med therapy includes antibiotics until the stent falls out, Tylenol for pain, and anticholinergic such as oxybutynin (Ditropan) for bladder spasms.

What client teaching for hypospadias should be performed?

1. Avoid giving child a tub bath until stent, if present, is removed.
2. Double diaper child to protect stent.
3. Limit activity for 2 weeks.
3. Restrict activities that put pressure on the site (riding toys, sitting on lap)
4. Give meds
5. Maintain adequate fluid intake & monitor for S/S of infection.
6. Call Dr. if urine leaks from anywhere but penis (urine will be blood tinged for several days).
7. Avoid contact with other children who may be infectious.

What can you admin to pt to help prior to hypospadias surgery?
Why?

male hormones to achieve bigger penis to help surgery

What is one way to identify boy with hypospadias?

abnormal urinary stream

If admitted for surgery of hypospadias, what do you assess?

child's perception of surgery and
what he calls his penis

How do you prepare child for hypospadias surgery?

use doll and put bandage and catheter on its penis (remind that penis is still there

What terms do you want to avoid for kid going into hypospadias surgery?

1. Corticosteroid therapy; monitor for S/S of infection and adverse effects. **reduces inflammatory process, which reduces proteinuria & edema quickly **7-21 days
2. Immunosuppresant therapy to reduce relapse rate and induce long term remission (if steroids don't work, therapy may be given along with the steroid).
3. Diuretics to reduce edema.
4. Plasma expanders such as salt-poor human albumin may be prescribed.
5. Antibiotics-- for any infection

1, It is acute inflammation of the glomeruli.
2. Acute post-infectious glomerulonephriitis is preceded by a strep infection, usually of the skin or resp. tract.
3. Damage is caused by an antigen-antibody complex that lodges in the glomeruli. An overproduction of antibodies stimulated by the infection may eventually settle in the glomeruli, causing inflammation. .

Here's my best explanation:
They are very similar, but the cause of the edema is different.

Glomerulonephritis is caused by immune complexes that deposit in the basement membranes of the glomeruli, which makes them edematous and infiltrated with leukocytes. This causes capillaries to occlude, basically resulting in water and sodium retention. Because interstitial fluid volumes are increased, the circulatory system becomes congested = edema.

Acute glomerulonephritis is a result of a streptococcal infection. It typically presents weeks after the infection has cleared, but is a direct result of the infection. Nephrotic syndrome has many causes from disease of the kidney to a condition that has affected another part of the body (like Hep B or diabetes mellitus).

The arterioles and capillaries of the body become obstructed by the resulting complexes of activated platelets which have adhered to endothelium via large multimeric vWF. The growing thrombi lodged in smaller vessels destroy red blood cells (RBCs) as they squeeze through the narrowed blood vessels, forming schistocytes, or fragments of sheared RBCs.

Most recover completely, if found early and no secondary problems were present

How do know if treatment for AGN is working?

If there is urine output!

Is nephrotic syndrome acute or chronic in nature?

Chronic.

Is AGN acute or chronic in nature?

Acute.

What is Wilm's tumor?

Wilms' tumor is a rare kidney cancer that primarily affects children. Also known as nephroblastoma, Wilms' tumor is the most common cancer of the kidneys in children. Wilms' tumor most often affects children ages 3 to 4 and becomes much less common after age 5.

Wilms' tumor most often occurs in just one kidney, though it can sometimes be found in both kidneys at the same time.

Symptoms of Wilm's tumor?

Wilms' tumor doesn't always cause signs and symptoms. Children with Wilms' tumor may appear healthy, or they may experience:

Abdominal swelling
****An abdominal mass you can feel (Firm, nontender, abdominal mass confined to one side of the abdomen)
Abdominal pain
urinary retention, hematuria, or both!
Fever
Blood in the urine
anemia (caused by hemorrhage within the tumor)
Pallor, anorexia & lethargy *resulting from anemia
Hypertension (caused by secretion of excess amounts of renin by tumor)

**Saunders pg. 530-531

Nursing considerations for Wilm's tumor?

Avoid palpation of the abd. in a child and be cautious when bathing, moving, or handling the child. It is important to keep the encapsulated tumor intact. Rupture of the tumor can cause cancer cells to spread throughout the abd, lymph system & bloodstream.

What is type 1 Diabetes?

Characterized by destruction of pancreatic beta cells, which produce insulin

Why is it a misnomer to say “juvenile onset”?

*Juvenile onset diabetes type 1- Has gone far away, because we now see Type 2 Diabetes in Children.

Not routinely used except to test q3h during illness and whenever glucose is ≥240 mg/dl when illness not present

Teach patient and family how to manage hypoglycemic episodes

Illness management

Management of DKA

What is diabetic ketoacidosis (DKA)?

This is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Ketoacidosis is the name for your body's state when it has started producing ketones, a high level of ketones causes the ph (acidity) of the blood to raise and this can cause coma and death in anyone.

OR (another explanation)

Diabetic ketoacidosis is a problem that occurs in people with diabetes. It occurs when the body cannot use sugar (glucose) as a fuel source because there is no insulin or not enough insulin. Fat is used for fuel instead.

Byproducts of fat breakdown, called ketones, build up in the body.

What's the most imp post op assessment for shunt r/t hydrocephalus?

^ ICP

If shunt for hydrocephalus, what position?

position flat or side-lying (to avoid to rapid decompression of IC fluid)

What's the most important assessment pre and post op r/t myelomeningocele?

^ ICP

What position do you put kid in w/ hydrocephalus r/t Myelomeningocele?

prone,
elevated head (to reduce ICP)

What 2 sym indicating what 2 neurological changes can you assess r/t myelomen?

1. Intraventricular catheter (allows continuous drainage) A drainage bag is attached to the system is kept at the level of the ventricles and can be lowered to decrease ICP.
2. Subarachnoid bolt (Richmond screw)
3. Epidural sensor
4. Anterior fontanel pressure monitor

5. Keep stimuli to a minimum, minimize crying in infant.
6. Withhold sedating meds, so that LOC can be assessed.
7. Seizure precautions (pad and raise side rails!)
8. Monitor for ▼ response to pain ( a sign. sign of altered LOC)
9. Maintain NPO status or provide clear liquids until it is determined that vomiting will not occur.
10. monitor IV fluids to avoid aggravating any cerebral edema and to minimize the possibility of over hydration.
11. Monitor for a fluid or electrolyte alteration (could indicate injury to hypothalamus or posterior pituitary).
12. Assess wounds & dressings for drainage, as well as the nose or ears. (May indicate leakage of CSF)
13. Administer tepid sponge bath or place the child on a hypothermia blanket to reduce temp.
14. Avoid suctioning the nares. (catheter might enter the brain through fracture, which places child at risk for infection).
15. Give tylenol for headache, anticonvulsants for seizures, antibiotics for laceration if present; prepare to administer prophylactic teanus toxoid.
16. Give steroids or osmotic diuretic to reduce cerebral edema.
17. Monitor for signs of brainstem involvement (deep, gasping resp, wide fluctuations in pulse, widening pulse pressure, etc).
18. monitor for signs of epidural hematoma; asymmetrical pupils (one dilated, nonreactive pupil).

**If drainage from nose or ear is tested positive for glucose, notify the Dr.! You must test the drainage. If positive for glucose, indicates CSF leakage.
**Prevent straining, such as during coughing, vomiting or defecating.

i. touch and massage the patient – but monitor the effects.
ii. let family visit and speak to the patient – but monitor the effects.
iii. try to get things done and then let the patient rest.

What is an EVD?

external ventricular drainage.

Nursing considerations for an EVD?

If unclamped for CSF drainage, carefully monitor the level of the collection container. If the container is too low, improper CSF decompression could lower ICP too rapidly, causing bleeding and pain.

Why does ICP rise or fall?

- Something blocks the normal drainage of csf
- Bleeding inside the head
- Edema (there are a couple of kinds, but both will make the affected tissue swell)
- “Mass effect” – something’s in there that shouldn’t be, and it’s taking up space where there isn’t any. If it’s big enough it can shove the brain over to one side, producing a “shift”.

Reasons for ICP to drop?

-Anything, basically, that reverses one of the processes just listed:

csf not draining? – drain some off!

Bleeding inside the head? Take out the clot!

Got edema? Do the mannitol thing, (mannitol is a hyperosmoltic diuretic.... will shrink the brain cells and then pee the ICP out!)

and so on. Obviously, the treatment is going to vary with the cause.

What is meningitis?

It is an infectous process of the central nervous system caused by bacteria or viruses that may be acquired as a primary disease or a result of complications of neurosurgery, trauma, infection of the sinuses or ears, or systemic infections.

Caused by various organisms; most commonly Haemophilus influenza type B, strep mneumoniae, can be transmitted by droplets from nasopharyngeal secretions.

What is viral meningitis?

Assocaited with virusrs such as mumps, paramyxovirus, herpesvirus, and enterovirus.

What is the difference between these two types of meningitis?

Viral meningitis is usually less severe and resolves without special treatment. Many different viruses can cause meningitis. Most of them are more common during the summer and fall months.Bacterial meningitis is extremely serious. It may result in brain damage, hearing loss or learning disability. It is important to know which type of bacteria is causing the meningitis

Treated with IV antibiotics for 7-14 days; get the vaccine to prevent infection! Contacts with the infant may receive Rifadin prophylactically.

What occurs in Reyes syndrome?

Reye's syndrome is a potentially fatal disease that causes numerous detrimental effects to many organs, especially the brain and liver, as well as causing a lower than usual level of blood sugar (hypoglycemia). The classic features are liver damage (fatty liver), cerebral edema, aspirin use and a viral infection.

Metabolic encephalopathy is temporary or permanent damage to the brain due to lack of glucose, oxygen or other metabolic agent, or organ dysfunction. Most cases occur when the liver cannot act normally to remove toxins from the bloodstream during an acute illness, but it can also be caused by a toxic overdose, or other systemic disease.

What causes Reyes syndrome?

While exact etiology is unclear, it usually develops after a mild viral illness such as chickenpox. Research has linked the development of Reye syndrome to the use of ASPIRIN.

As soon as parents used only acetaminophen or ibuprofen, incidence of Reye syndrome decreased!

Surgical insertion of a tube or shunt into ventricles with the end in either the peritoneum or atrium; the most common version is ventriculoperitoneal;

Preop-- monitor child for increased ICP
POST- position child flat and on unoperative side; if held, it is important not to allow the head to be elevated.

What do you need to teach a family with a child with hydrocephalus?

1. Teach caregiver S/S of shut infection and malfunction and what actions to take should symptoms develop.
2. Some children with hydrocep. have brain damage that results in motor, language, perceptual, and intellectual disabilities; parents may need referrals to early intervention professionals to provide long term rehabilitation services.
3. May have increased risk of latex allergies; teach parents to avoid nipples. pacifiers, and toys made out of latex products.

Older children have difficulty with balance/coordination.
All children have lethargy and Cheyne-Stokes respirations.

What long term management/care is required?

Hydrocephalus is a life-long problem and the child will require evaluation on a regular basis. Parents should know how to recognize signs that indicate shunt malfunction or infection and how to pump the shunt.

Seizures are alterations in firing of neurons in brain; is the result of cortical neuronal discharge; the result of this discharge (seizure activity) depends on where in brain discharge begins and how it spreads.

1. Ensure airway patency (position on side and head down).
2. Have suction equipment and O2 available.
3. If the child is standing or sitting, ease the child down to the floor and place in a side-lying position.
4. Place a pillow or folded blanket under child's head; if not available, place your own hands under the head or place child's head in your lap.
5. Loosen restrictive clothing.
6. Remove eyeglasses.
7. Clear the area of any hazards/objects.
8. Allow seizure to proceed and end w/o interference.
9. if vomiting occurs, turn child to side as a unit.
10. DO NOT RESTRAIN, PLACE ANYTHING IN MOUTH, OR GIVE ANY FOODS/LIQUIDS.
11. Give meds/remain with the child until he fully recovers.
12. Observe for incontinence
13. Document and TIME the seizure!

Seizure precautions?

1. Raise side rails when child is sleeping.
2. Pad side rails and other hard objects.
3. instruct child to use protective helmet when outside playing.
4. place water-proof mattress or pad on bed or crib for incontinence during seizure.

What are some common seizure medications? (see pg. 968 Saunders book).

Meds are teratogenic– harmful to pregnant teenagers. Make sure they are on birth control.

**Ketogenic diet -- High fat, adequate protein, low CHO.

Why do get levels of seizure drugs?

Since people can become more sensitive to medications as they age, they may need to have their blood levels of medication checked occasionally to see if the dose needs to be adjusted. The effects of a particular medication also sometimes wear off over time, leading to an increase in seizures if the dose is not adjusted. People should know that some citrus fruit, in particular grapefruit juice, may interfere with breakdown of many drugs. This can cause too much of the drug to build up in their bodies, often worsening the side effects.

What is a "loading dose?"

A loading dose is an initial higher dose of a drug that may be given at the beginning of a course of treatment before dropping down to a lower maintenance dose.[1]

A loading dose is most useful for drugs that are eliminated from the body relatively slowly. Such drugs need only a low maintenance dose in order to keep the amount of the drug in the body at the appropriate level, but this also means that, without an initial higher dose, it would take a long time for the amount of the drug in the body to reach that level.

Phenytoin for acute status epilepticus should also be given with an initial loading dose, co-administered with a benzodiazepine, to immediately stabilize neuronal membranes and electrical activity during a seizure.

http://en.wikipedia.org/wiki/Loading_dose

What do you have to watch for with a loading dose?

Respiratory depression. NOTE: Higher doses have to be given over a longer time!

1. Usually well-circumscribed, gray or brown, elevated, firm papules with a roughened, finely papillomatous texture
2. Occur anywhere, but usually appear on exposed areas such as fingers, hands, face, and soles
3. May be single or multiple
4. Asymptomatic

1.Grouped, burning, and itching vesicles on inflammatory base, usually on or near mucocutaneous junctions (lips, nose, genitalia, buttocks)
2. Vesicles dry, forming a crust, followed by exfoliation and spontaneous healing in 8-10 days
3. May be accompanied by regional lymphadenopathy

1. Keep affected area clean
2. Promote good nutrition/hydration
3. Apply topical agents as indicated
4. Administer antimicrobials orally or intravenously, if needed
5. Keep it open to air as much as possible, but cover as necessary
6. Prevent further injury and secondary infection

Anti-fungal meds

Antifungals: Lotrimin & Nystatin

1. Prevention of Diaper Rash important
2. Any "tinea" of any kind is a fungus.

Treatment
1. Apply scabicial lotion to cool, dry skin over entire body from chin down.
2. Leave on for 8-12 hrs before washing off.
3. All family members and close contacts (playmates and caregivers) should be treated.
4. clothing, bedding, towels should be changed daily and washed in hot water dried in hot dryer.
5. Treat with Permethrin 5% cream (Elimite) ***APPLY LOTION TO COOL, DRY SKIN 30 MIN AFTER BATHING Leave on for 8-12 hrs before washing off.

Teaching
1. Not all lesions clear immediately and, along with itching, may persist 2-3 wks until epidermis is replaced.
2. All persons in house-hold should be treated.
3. Children should NOT share clothes, towels or hygiene items.

1. May have gradual or abrupt onset
2. Tick acquired disease (most often from rodents or dogs)
3. Maculopapular rash on extremities (ankles and wrists), but may spread to other areas, esp. on the palms and soles.
4. Ask if they have "been camping outside the area in the woods?"

• Teach children to avoid all strange animals, especially wild, sick, injured ones, who may be carriers of rabies (use the same techniques employed in teaching children not to talk to strangers).
• Teach children to avoid dangerous and nervous animals in the neighborhood.
• Vaccinate your own dog against rabies.
• Never permit children to break up an animal fight, even when own pet is involved. Use a rake, broom, or garden hose to separate animals.
• Teach children the danger of mistreating or teasing pets (animals bite if mauled, annoyed, or frightened).
• Spay or neuter your pets (spaying or neutering reduces aggression, not protectiveness).
• Avoid direct eye contact with a threatening dog, and remain motionless until a threatening dog leaves the area.
• Never hold your face close to an animal.
• Teach children not to disturb an animal that is eating; sleeping; caring for young puppies, kittens, etc.
• Never tease; pull the tail; or take away food, a bone, or a toy with which an animal is playing.
• Never approach a strange dog that is confined or restrained; do keep animals confined with short ropes or chains (this can make them aggressive or vicious, especially when teased).
• Do not run, ride a bicycle, or skate in front of a dog (it will startle dog); teach children the importance of avoiding bike routes where dogs are known to chase vehicles.
• Do not allow an inexperienced child or adult to feed a dog (if the person pulls back when the animal moves to take the food, this frighten and startle the animal).
• If a dog is asleep or unaware of your presence, or has not seen approach, speak to the animal to make it aware of your presence avoid startling the animal.
• Allow a dog to see and sniff a child before the child attempts to the animal.
• Do not permit a child to lead a large dog.
• Train or socialize a dog for appropriate behavior; avoid aggressive play with pets.
• Do not adopt pets for children until children demonstrate their maturity and ability to handle and care for pets.

What are the 4 types of dermatitis?

Diaper
Atopic (Eczema)
Seborrheic (Cradle Cap)
Acne

Diaper dematitis?

**Breakdown on butt should be confined to labia & cheeks.
**Trademark of candida travels up the thighs!
**Treat with anti-fungals.